Expandable Spacer and Method of Use Thereof

ABSTRACT

An expandable implant is disclosed having an adjustable height for insertion between two adjacent bony structures or joint surfaces, for example between two adjacent spinal vertebrae. The implant includes at least one gear associated with at least one threaded shaft. Rotation of the gear engages the threaded shaft to expand the implant. The implant can be inserted in a collapsed configuration and expanded in situ. The invention also provides methods for using the implant to facilitate arthrodesis or fusion of adjacent joint surfaces or spinal vertebrae.

CROSS-REFERENCE TO RELATED APPLICATIONS

This Application is a Continuation Application of U.S. patentapplication Ser. No. 12/615,806 filed on Jan. 12, 2010, which is hereinincorporated by reference in its entirety.

FIELD OF THE INVENTION

The invention generally relates to spacers for use in orthopedictreatments, particularly to implants for insertion between two adjacentbony structures or two adjacent joint surfaces, and most particularly,to an expandable implant for insertion into the void remaining in theintervertebral space after removal of damaged disc material.

BACKGROUND OF THE INVENTION

The vertebral or spinal column (spine, backbone) is a flexible assemblyof vertebrae stacked on top of each other extending from the skull tothe pelvic bone which acts to support the axial skeleton and to protectthe spinal cord and nerves. The vertebrae are anatomically organizedinto four generalized body regions identified as cervical, thoracic,lumbar, and sacral; the cervical region including the top of the spinebeginning in the skull, the thoracic region spanning the torso, thelumbar region spanning the lower back, and the sacral region includingthe base of the spine ending with connection to the pelvic bone. Withthe exception of the first two cervical vertebrae, cushion-like discsseparate adjacent vertebrae, i.e. intervertebral discs.

The stability of the vertebral column during compression and movement ismaintained by the intervertebral discs. Each disc includes a gel-likecenter surrounded by a fibrous ring. The gel-like center, i.e. nucleuspulposus, provides strength such that the disc can absorb and distributeexternal loads and contains a mixture of type II-collagen dispersed in aproteoglycan matrix. The fibrous ring, i.e. annulus fibrosus, providesstability during motion and contains laminated rings of type-I collagen.Thus, the annulus fibrosis and the nucleus pulposus are interdependent,as the annulus fibrosis contains the nucleus pulposus in place and thenucleus pulposus aligns the annulus fibrosus to accept/distributeexternal loads. The integrity of the composition and structure of theintervertebral disc is necessary to maintain normal functioning (of theintervertebral disc).

Many factors can adversely alter the composition and structure of theintervertebral disc, such as normal physiological aging, mechanicalinjury/trauma, and/or disease, resulting in impairment or loss of discfunction. For example, the content of proteoglycan in the nucleuspulposus declines with age, thus, it follows that the ability of thenucleus pulposus to absorb water concurrently declines. Therefore, innormal aging the disc progressively dehydrates, resulting in a decreasein disc height and possible de-lamination of the annulus fibrosus.Mechanical injury can tear the annulus fibrosis allowing the gel-likematerial of the nucleus pulposus to extrude into the spinal canal andcompress neural elements. Growth of a spinal tumor can impinge upon thevertebrae and/or disc potentially compressing nerves. Regardless of thecause, many of these disc pathologies become severe enough to requiresurgical intervention

In most cases, this surgical intervention is a partial or completeremoval of the damaged intervertebral disc material (discectomy). Whilethe discectomy eliminates the problems associated with the damaged disc,it creates a void in the intervertebral space that, if left empty, cande-stabilize and possibly collapse the vertebrae, negatively affectingthe whole vertebral column.

The stabilization of the spine has been a focus of medical research forover 100 years. Early efforts at stabilization included spinal fusion.Spinal fusion was first used to treat the symptoms of spinaltuberculosis (Pott's disease) including the collapse of vertebral bodiesand abnormal curvature of the spine. In this technique, bone tissue washarvested from the patient and applied to the dorsal spine. See Ryerson,Dr. Edwin W., The Journal of Bone and Joint Surgery; s2-12:259-264,1914; wherein treatment of patients using the bone-graft proceduredeveloped by Dr. Fred Albee is discussed. The entire contents areincorporated herein by reference. Although this basic technique is stillin use today, bone grafts alone are slow to fuse and may not beanatomically correct even if fusion is achieved. Furthermore, such bonegrafts are often not strong enough to maintain long-term stability ofthe spine.

In order to facilitate solid fusion and further stabilize vertebrae,various implantable hardware systems have been devised. These systemsare applied to the surface of the spine and can compress the bone graftarea to accelerate fusion. For example, an instrument, such as a rod, isplaced generally parallel to a patient's back and attached to selectedvertebrae by screws, clips, hooks, and/or clamps. Although this type ofsystem initially offers strength, the hardware can loosen over timedecreasing this strength.

In addition to spinal stabilization hardware, an extensive variety ofdevices for placement within the intervertebral space has beendeveloped. For example, Harms, et al. (U.S. Pat. No. 4,820,305) providesa prosthesis in the form of a hollow cylindrical jacket which acts as a“place holder” between vertebrae. Buettner-Janz, et al. (U.S. Pat. No.4,759,766) provides an intervertebral disc endoprosthesis including twoendplates with an intermediate spacing device. Other devices combinestructural elements with bone graft material. For example, Bagby (U.S.Pat. No. 4,501,269) discloses an implantable basket. In order to insertthe basket, a hole is bored transversely across a joint. The boneshavings are collected and placed in a basket that is slightly largerthan the hole. The basket is then driven into the hole to spread thebones. The entire contents of the '305, '766, and '269 patents areincorporated herein by reference.

Brantigan (U.S. Pat. No. 5,192,327) provides an annular implant withrigid surfaces having spaces for packing of bone graft material. Therigid surfaces engage the adjacent vertebral bodies to resistdisplacement. The annular implant may be inserted singly or multipleimplants can be inserted as a set. The implants of the set can havedifferent thicknesses and are internally grooved to receive a connectingbar to bind the implants together. The entire contents of the Brantigan'327 patent are incorporated herein by reference.

Despite the enormous progress in spinal therapy, chronic back painremains a perplexing problem and the number of patients with backproblems continues to rise.

Thus, ongoing efforts are desired to improve treatments and curtail theproblem.

SUMMARY OF THE INVENTION

An expandable implant having an adjustable height for insertion betweentwo adjacent bony structures or two adjacent joint surfaces isdisclosed. In one variation, the implant may include at least one gear,at least one threaded shaft, and a base or collar. The parts (gear,shaft, base) can be any size capable of functioning to expand theimplant. Insertion of the implant facilitates arthrodesis or fusion ofthe bony structures or joints. Although intended to be useful with anyadjacent bony structures or joint surfaces in which fusion is desired,the implant is particularly applicable to the spine, wherein it isinserted into the intervertebral space remaining after removal ofdamaged disc material.

In one embodiment, the implant includes a gear associated with athreaded shaft and a base. Rotation of the gear initiates rotation ofthe shaft to extend the shaft axially to the longitudinal axis of theimplant. The shaft is extended to contact and engage one of the adjacentbony structures such that the bony structures are separated by theexpanded implant. The threaded shaft has at least one side edge and achannel. The channel extends along the side edge parallel with thelongitudinal axis of the shaft. The base is a housing for receiving theshaft and includes a projection, advantageously at a top end of thebase, configured for engagement with the channel along the side edge ofthe shaft. The gear is coupled with the shaft and the base. Interiorthreading of the gear engages with the threading on the shaft. Theengagement of the projection with the channel enables the rotation ofthe gear to extend the shaft, preventing rotation of the shaft in place.

In one embodiment, the implant includes a pair of actuation gearsassociated with at least two threaded shafts, and a base plate. Rotationof the gears initiates rotation of the threaded shafts to extend theshafts axially to the longitudinal axis of the implant. The base platehas an exterior surface and an interior surface. The interior surface ofthis plate includes a housing configured for receiving the at least twothreaded shafts. As shown herein, a first threaded shaft and a secondthreaded shaft extend from the base plate in a substantially parallelconfiguration or in an angled configuration. The exterior surface of thebase plate can additionally include a plurality of protrusions. Theprotrusions enhance engagement of the plate with the bony structures andmay extend into the bone to stabilize and secure the implant in place.

Mechanical interaction of the pair of gears with the threaded shaftsextends the shafts. The first gear of the pair is operably coupled withthe first threaded shaft and the second gear of the pair is operablycoupled to the second threaded shaft. Upon actuation, the first gearrotates in a first direction. This rotation of the first gear in thefirst direction initiates rotation of the second gear in a seconddirection opposite the first direction. This activation of the pair ofgears rotates, and thus also, extends the shafts. The extended shaftscontact and engage one of the adjacent bony structures such that thebony structures are separated by the expanded implant.

The threading and/or gears may be arranged in alternate ways. In theforegoing embodiment, the first and second threaded shafts exhibitopposite threading. For example, if the first threaded shaft has aright-handed thread, the second threaded shaft has a left-handed thread,or vice versa. If both shafts have the same type of threading, the gearscan be uncoupled and another gear, or idler gear, placed between the twogears, enabling rotation of both gears in a same direction. Additionalinterposed gears may be employed to change a relative movement and/ordirection between the driving gear and the driven gear.

In another embodiment, the shafts have the same or different directionof threading, but with differing thread pitch, enabling each shaft torise at a different rate. Also, the pair of gears may be uncoupled suchthat the first threaded shaft and the second threaded shaft operate assingle independent units. This arrangement enables each shaft to extendto a different height if needed, for example, to remove pressure fromone area or to provide pressure to an injured area, or to adjust anangle of the two contacted bones.

In one embodiment, the implant includes a pair of actuation gearsassociated with at least two threaded shafts interposed between a topplate and a bottom plate. Rotation of the gears initiates rotation ofthe threaded shafts to extend the shafts axially to the longitudinalaxis of the implant. The top plate includes an exterior surface and aninterior surface. A first threaded shaft and a second threaded shaftextend from the interior surface in a substantially parallelconfiguration. As the top plate connects the two shafts, preventingrotation of the shafts, a channel in a side of a shaft, and acooperating projection from the base, are not needed to prevent arotation of a shaft.

Further, as the shafts are connected, the first and second threadedshafts exhibit opposite threading. For example, if the first threadedshaft has a right-handed thread, the second threaded shaft has aleft-handed thread, and vice versa. Or if both shafts have the same typeof threading, the gears can be uncoupled and another gear placedtherebetween, to establish a common direction of rotation.

The bottom plate also has an exterior surface and an interior surface.The interior surface of this bottom plates includes a housing configuredfor receiving the first and second threaded shafts. One or both of theexterior surfaces of the top and bottom plate can additionally include aplurality of protrusions. The protrusions enhance engagement of theplates with the bony structures and may extend into the bone tostabilize and secure the implant in place.

Mechanical interaction of the pair of gears with the threaded shaftsextends the top plate. The first gear of the pair is operably coupledwith the first threaded shaft and the second gear of the pair isoperably coupled to the second threaded shaft. Upon actuation, the firstgear rotates in a first direction. This rotation of the first gear inthe first direction initiates rotation of the second gear in a seconddirection opposite the first direction. This activation of the pair ofgears rotates the shafts to extend the top plate. The extended top platecontacts and engages one of the adjacent bony structures such that thebony structures are separated by the expanded implant.

In any embodiment, the gears can be rotated by manually engaging theexterior teeth or surface of a gear using fingers or a tool, or therotation can be robotically assisted.

A motor, powered by electricity, hydraulic pressure including forexample air or water, or other form of propulsion may be used to driveone or more gears to extend a shaft. The motor may be remotelycontrolled, in a manner known in the relevant art. A power source may beimplanted within the patient to power the motor.

Any of the described implants can be used to achieve distraction (of thebony surfaces) without the necessity of a distraction tool. Adistraction tool applies force to displace the bony surfaces.Conventional implants often require a distraction device, for example asdisclosed by Ray (U.S. Pat. No. 6,599,292 B1, the entire contents ofwhich are incorporated herein by reference), for insertion andpositioning within the disc space. Furthermore, conventional implants,which are capable of applying enough force to accomplish adequatedistraction of vertebral bodies, can be too large to be inserted viaminimally-invasive incisions. Moreover, the use of each additional toolimposes further risk to the patient. The invention advantageouslyreduces the number of tools needed to safely accomplish the objectivesof distraction and or support.

When in the collapsed configuration, the implant of the invention can begently inserted through a small incision using any appropriateminimally-invasive procedure. The implant is then expanded in situ,wherein the expansion itself distracts the vertebrae without undesirabledistraction force imposed elsewhere in the body, including for examplean expansion of the incision. Reduction of the force applied, and areaof applied force, when inserting the implant of the invention rendersthe procedure safer and less painful for the patient during recovery,with a shorter required recovery period.

In the embodiments including plates, the top plate, bottom plate, orboth plates can additionally include at least one opening or aperturethrough which therapeutic material may be inserted into an area betweenthe interior surface of the top plate and the interior surface of thebottom plate, for example within the shafts, or alternatively throughother means of confinement of the material, for example netting or othercontainment surfaces. The hollow spaces may pass into the threadedshafts, wherein the shafts provide a receptacle for the insertedmaterial. The material can include any of the following: osteogenicmaterial, such as bone graft material, growth factors, differentiationfactors, healing agents, analgesics, or antimicrobial agents.

Upon installation, the openings or apertures through the plates allowfor bone growth into the interior spaces such that any new bone growthpresent therein can contact and fuse therethrough with the existing boneto further stabilize the implant and/or the bony structures.

Furthermore, in addition to access through a top or bottom plate, any ofthe threaded shafts can have a hollow interior space accessible throughan opening near a shaft end, accessible when the device of the inventionhas been installed. In this manner, additional material may be insertedafter a shaft has been expanded, where the interior volume of the shafthas been increased. In this manner, the material may extend from asurface of a first bone to a surface of a second bone, promoting, forexample, contiguous bone growth.

The invention includes methods for using the described implants tofacilitate arthrodesis or fusion of adjacent bony surfaces or jointsurfaces, including, but not limited to spinal vertebrae. Although thismethod is advantageously used with vertebrae, it is contemplated for usewith any adjacent bones and/or bony structures. The steps includeaccessing the two adjacent bony surfaces to be fused in the patient'sbody, providing the implant in the collapsed configuration, preparingthe space between the bony surfaces for insertion of the implant,inserting the implant, actuating the gear or gears, extending the shaftsand or any associated plates to the expanded configuration to engage oneor more of the adjacent bony surfaces, and then closing the surgicalsite in an accepted manner.

In addition to the aforementioned projections, devices of the inventionmay be further secured against displacement, for example, by insertingfasteners through a portion of the device, into surrounding tissue. Forexample, an aperture may be provided in a top or bottom plate, and abone screw may be inserted therethrough in a manner known in the art tosecure the device to the associated bone. Adhesive or other methodsknown to one skilled in the art may also be used for this purpose.

Further, an undesired rotation of a gear, or movement of a shaft, may beprevented by applying an adhesive between a gear and the body, a shaftand the body, or a gear and a shaft, for example. In order to enable afuture adjustment of the device, removable adhesive is advantageous.Alternatively a set screw or through screw may be provided to secure anymoving part of the device, to prevent movement of same once anadvantageous position has been established.

Devices in accordance with the invention are useful for spacing anddistraction in many different orthopedic treatments.

Devices of the invention thus provide: an expandable implant having anadjustable height; an expandable implant having a first, collapsedheight prior to expansion and a second, expanded height after expansion;an implant that can be inserted via a minimally-invasive surgicalprocedure and expanded in situ; an implant that can be inserted via aminimally-invasive surgical procedure and expanded in situ to restorethe height of an intervertebral disc space; an implant that can achievedistraction without the necessity of a distraction tool; an expandableimplant which can be adjusted intraoperatively, for example, the implantcan be collapsed, expanded, and re-fitted if a previous attempt to fitit is unsatisfactory or a condition has changed; an expandable implantfor insertion between two adjacent bony structures; an expandableimplant for insertion between two adjacent joint surfaces; an expandableimplant for insertion between two adjacent spinal vertebrae; anexpandable implant for facilitation of arthrodesis or fusion of twoadjacent bony structures; an expandable implant for facilitation ofarthrodesis or fusion of two adjacent joint surfaces; an expandableimplant for facilitation of arthrodesis or fusion of two adjacent spinalvertebrae; an expandable implant for restoring the height and shape ofan intervertebral disc space after removal of damaged disc material;and/or an expandable implant for treatment of degenerative disc disease(DDD).

The implant advantageously supplements and/or replaces disc materialsuch that degenerated discs can be removed from the patient withoutdestroying the structure/function of the spinal motion segment.

Other aspects of the invention include providing: an in vivo receptaclefor material; an in vivo receptacle for osteogenic material; an implantcontaining bone graft material; an implant containing bone graftmaterial and an effective amount of a growth factor or differentiationfactor; an expandable implant that expands via interaction of anassociated threaded gear(s) with a threaded shaft; an expandable implanthaving a gear associated with a threaded shaft and a base; an expandableimplant having a pair of actuation gears associated with at least twothreaded shafts, and a base plate; an expandable implant having a pairof coupled actuation gears with at least two associated threaded shaftsinterposed between a top plate and a bottom plate; an expandable implanthaving a pair of uncoupled gears; an expandable implant having a pair ofmated gears; an expandable implant which is mechanically activated viaright-handed left-handed threading; an implant having at least twothreaded shafts with the same type of threading; an implant having atleast two threaded shafts with the same type of threading, but withdifferent pitches of the threading; an expandable implant including atleast two threaded shafts having the same type threading and idler gearseparating a driver gear and a driven gear; an implant that is capableof achieving distraction of bony structures without the necessity of adistraction tool; an implant that is capable of achieving distraction ofjoint surfaces without the necessity of a distraction tool; an implantthat is capable of achieving distraction of spinal vertebrae without thenecessity of a distraction tool.

Further aspects of the invention provide: a method for facilitatingfusion of two adjacent bony structures in a patient; a method forfacilitating fusion of two adjacent joint surfaces in a patient; amethod for facilitating fusion of two adjacent spinal vertebrae in apatient; a method for restoring the height and shape of anintervertebral disc space after removal of damaged disc material; amethod for treating degenerative disc disease (DDD) by using thedescribed implants to replace degenerated discs and thus, restorestructure and function to the spinal motion segment; a method fordistracting bony structures; a method for distracting joint surfaces;and/or a method for distracting vertebral bodies; a method fordistracting vertebral endplates.

Other objectives and advantages of this invention will become apparentfrom the following description taken in conjunction with theaccompanying drawings, wherein are set forth, by way of illustration andexample, certain embodiments of this invention. The drawings constitutea part of this specification and include exemplary embodiments of thepresent invention and illustrate various objects and features thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

A more complete understanding of the present invention may be obtainedby references to the accompanying drawings, when considered inconjunction with the subsequent detailed description. The embodimentsillustrated in the drawings are intended only to exemplify the inventionand should not be construed as limiting the invention to the illustratedembodiments, in which:

FIG. 1 is a perspective view of a healthy intervertebral disc;

FIG. 2A is a front plan view of one embodiment of the implant in anexpanded configuration;

FIG. 2B is a front plan view of the implant shown in FIG. 2A in thecollapsed configuration;

FIG. 2C is a front cross-sectional view of the implant shown in FIG. 2A;

FIG. 2D is a cross-sectional view of the gear shown in FIG. 2A;

FIG. 2E is an enlarged cross-sectional view of the engagement of thechannel and the projection of the implant shown in FIG. 2A;

FIG. 2F is a front view of the threaded shaft of the implant shown inFIG. 2A;

FIG. 3A is a front plan view of another embodiment of the implant in anexpanded configuration;

FIG. 3Ai is top view of the gears of the implant shown in FIG. 3A;

FIG. 3B is a front plan view of the implant shown in FIG. 3A in thecollapsed configuration;

FIG. 3C is a front cross-sectional view of the implant shown in FIG. 3A;

FIG. 3D is a front plan view of the implant shown in FIG. 3A withuncoupled gears in an expanded configuration;

FIG. 3E is a front plan view of an embodiment of the implant with idlergears in the expanded configuration;

FIG. 3F is a top view of the idler gears of the implant shown in FIG.3E;

FIG. 3G is a front plan view of the base plate of the implant shown inFIG. 3A having an attached wedge tool;

FIG. 3H is a front plan view of an embodiment of the implant in theexpanded configuration having shafts in an angled configuration;

FIG. 4 is a front plan view of another embodiment of the implant in anexpanded configuration;

FIG. 5 is a front plan view of the implant shown in FIG. 4 in thecollapsed configuration;

FIG. 6 is a top plan view of the top plate of the implant shown in FIG.4;

FIG. 7 is a front cross-sectional view of the implant shown in FIG. 4;

FIG. 8 is a sagittal plane view showing a cross-sectional side view ofthe implant shown in FIG. 5 inserted between two adjacent vertebrae; and

FIG. 9 is a sagittal plane view showing a cross-sectional side view ofthe implant shown in FIG. 4 in an expanded position.

DETAILED DESCRIPTION OF THE INVENTION

For the purpose of promoting an understanding of the principles of theinvention, reference will now be made to embodiments illustrated hereinand specific language will be used to describe the same. It willnevertheless be understood that no limitation of the scope of theinvention is thereby intended. Any alterations and further modificationin the described implants, methods, and any further application of theprinciples of the invention as described herein, are contemplated aswould normally occur to one skilled in the art to which the inventionrelates. The implants described herein are not limited to the specificembodiments.

In general, the invention provides an expandable implant having anadjustable height. The implant is inserted between two adjacent bonysurfaces to facilitate fusion of the bony surfaces. Although intended tobe useful with any adjacent bony surface in which fusion is desired, theimplant is advantageously applied to insertion between two adjacentvertebral bodies in any section of the spine, including the cervical,thoracic, lumbar, and sacral vertebral sections. Any number or type ofimplant can be used in a patient, for example, insertion of an implanthaving two threaded shafts between lumbar vertebrae and insertion of animplant having one threaded shaft between two cervical vertebrae. Theuse of multiple implants is particularly advantageous for patients whoseback pain is not limited to a localized area or patients whose localizeddamage has progressed to other areas of the spine.

Any one or all of the members of the implants can be made from anybiocompatible material, including synthetic or natural autograft,allograft or xenograft tissues, and can be resorbable or non-resorbablein nature. Examples of tissue materials include hard tissues, connectivetissues, demineralized bone matrix and combinations thereof. Furtherexamples of resorbable materials are polylactide, polyglycolide,tyrosine-derived polycarbonate, polyanhydride, polyorthoester,polyphosphazene, calcium phosphate, hydroxyapatite, bioactive glass, andcombinations thereof. Further examples of non-resorbable materials arenon-reinforced polymers, carbon-reinforced polymer composites, PEEK andPEEK composites, shape-memory alloys, titanium, titanium alloys, cobaltchrome alloys, stainless steel, ceramics and combinations thereof andothers as well.

The implant can be manufactured using any method for making objects outof these materials. Particularly applicable are methods for moldingplastics, for example injection molding or blow molding. Blow molding isparticularly useful for manufacture of hollow parts such as the threadedshafts. Also applicable are methods for cutting metal and/or for makingmetal parts, for example, shearing, laser cutting apparatus, andwaterjets. The implant can be manufactured as a whole or fabricated fromindividual parts. The parts may be snapped or welded together in anumber of different ways. A gear can be coupled with a shaft and thenmounted to a base. A gear can be mounted to a base and the shaftinserted therein.

After assembly, the implants can be sterilized and packaged.Sterilization can be accomplished by autoclave, ultraviolet lamp, bleachsolutions, alcohol solutions, and/or combinations thereof. The implantscan be packaged individually or in groups using any material suitablefor packaging medical items.

The implant and methods for its insertion can be used in a treatmentprotocol for any condition in a patient involving diseased or damagedbony structures. The patient can be a human being. Additionally, it iscontemplated that the implant may be useful in veterinary science forany animal having adjacent bony structures to be fused. The implant cancollapse, for example, to approximately one half of its expanded size.When in this collapsed configuration, the implant can be inserted into aspace through a small incision and narrow pathways using appropriateminimally-invasive techniques, positioned across the space, and expandedto the desired height. The incision may be short, for example about oneinch in length, smaller than the implant in an expanded configuration.If the desired position and/or expansion are not achieved, the implantcan be collapsed, repositioned, and expanded in situ.

Although the implant is exemplified herein for use in the spine, theimplant is contemplated for fusion of any bony structures. Whilst theimplants are described herein using several embodiments, the implantsare not limited to these embodiments. An element of one embodiment maybe used in another embodiment or an embodiment may not include alldescribed elements.

Referring now to the figures, a healthy intervertebral disc 1 isillustrated in FIG. 1. The intervertebral disc 1 includes a gel-likecenter, the nucleus pulposus 3, surrounded by a fibrous ring, theannulus fibrosis 2. The relationship between the structure and functionof the nucleus pulposus 3 and the annulus fibrosis 2 is essential tomaintain health of the intervertebral disc 1. A healthy nucleus pulposus3 exhibits hygroscopic properties. For example, as the disc 1 absorbswater, the intra-nuclear pressure increases, swelling the nucleuspulposus 3 expanding the height 4 of the disc, and in turn, tensioningthe fibers of the annulus fibrosis 2. Many factors can adversely alterthe structure and function of the intervertebral disc, such as normalphysiological aging, mechanical injury/trauma, and/or disease. Since thedisc is avascular any damage is, more often than not, irreversible.Damaged discs are either partially or fully removed, leaving spacebetween the adjacent vertebrae.

The expandable implant of the invention is suitable for insertion intothe intervertebral space to restore the height and shape of the space.The implant has a first, collapsed height and a second, expanded height.

In the embodiment illustrated in FIGS. 2A-2F, the implant 5 includes agear 6 operably coupled with a threaded shaft 7 and a base 8. Base 8 ishousing for receiving threaded shaft 7. The first, collapsedconfiguration of implant 5 is shown in FIG. 2B and the second, expandedconfiguration in FIG. 2A. The expandable configuration is adjustable andcan be set in any position along the length of the partially or fullyextended threaded shaft 7. The interior surface 9 of gear 6 has threads10 and the exterior surface 11 has teeth 12 (FIG. 2D). The rotation ofgear 6 can be initiated manually, or by engaging teeth 12 with a tool.Alternatively, rotation may be initiated with robotic assistance. Therotation of gear 6 initiates rotation of shaft 7, the rotation extendingthe shaft 7 in a direction axial (indicated by arrow A in FIG. 2A) tothe longitudinal axis 13 of the implant 5. The threading 10 of gear 6engages with the threading 7 a of shaft 7 to produce axial movement ofshaft 7. Shaft 7 can be extended until it separates the adjacent bonysurfaces by contacting and engaging one or more of the adjacent bonysurfaces. Threaded shaft 7 has at least one side edge 14 and a channel15. Channel 15 extends along side edge 14 parallel to longitudinal axis13 forming an indented groove. The base 8 includes a projection 16 neara top end 17 (FIG. 2E). Projection 16 engages with channel 15 to preventthreaded shaft 7 from rotating in place. The projection 16 engages alongthe length of channel 15 until the desired extension is reached.

A stop may be provided to prevent overextension, for example the channelmay stop (not shown) along side edge 14, or threads may discontinuealong shaft 7. The engagement of channel 15 and projection 16 isillustrated in FIG. 2E. Threaded shaft 7 can be hollow forming a spacewhich can function as a receptacle 18 for inserted material 19 (FIG.2C). The hollow interior 18 is accessible through a hole or aperture 21at a top end 20 of shaft 7 (FIG. 2F). The inserted material 19 caninclude osteogenic material, bone graft material, growth factors,differentiation factors, hormones, cytokines, and combinations thereof.

After installation of the implant 5, inserted material 19 can maintaincontact with the bone through aperture 21. This contact facilitatesfusion of the bony surfaces. Although the implant 5 does not require anysupplemental fixation, further fixation of the implant in the body canbe accomplished with the installation of devices such as rods, screws,and plates.

In the embodiment illustrated in FIGS. 3A-3H, the implant 22 includes apair of actuation gears (23 a and 23 b) operably coupled with at leasttwo threaded shafts (24 a and 24 b) and a base or bottom plate 25.Although this embodiment is exemplified by two threaded shafts, three ormore shafts may be used. Although, in FIG. 3A the threaded shafts 24 aand 24 b are shown as extending from the base plate 25 in asubstantially parallel configuration an angled extension of the threadedshafts is also contemplated. In an embodiment of the implant 22 i, thethreaded shafts 32 a and 32 b are shown in FIG. 3H in an angledconfiguration.

The first, collapsed configuration of implant 22 is shown in FIG. 3B andthe second, expanded configuration in FIG. 3A. The expandableconfiguration is adjustable and can be set in any position along thelength of the partially or fully extended threaded shafts 24 a and 24 b.The base plate 25 has an exterior surface and an interior surface. Theinterior surface 26 of the base plate 25 includes a housing (27 a and 27b) configured for receiving the at least two threaded shafts (24 a and24 b).

As shown in FIG. 3C, gears 23 a, 23 b are retained in rotatableconnection to bottom plate 25 by an interlocking projection 25A inbottom plate 25, and groove 23D in gear 23 a, although a groove may beprovided in bottom plate 25 and a corresponding projection in gear 23 b.Alternative means of rotatably retaining gear 23 a, 23 b upon bottomplate 25 may be provided, as would be understood to one skilled in theart.

The exterior surface 28 of the base plate 25 can include a plurality ofprotrusions 29. The protrusions 29 enhance engagement of the base plate25 with the bony surface and can extend into the bone to stabilize andsecure the implant in place. This stabilization may reduce the chancesfor dislodgement over the life of the implant.

A wedge 42 can be attached to or incorporated within base plate 25 (FIG.3G). Wedge 42 enables an angular displacement of base plate 25, topreserve or establish a correct angular displacement of bones betweenwhich device 22 is implanted.

Gear 23 a is operably coupled with threaded shaft 24 a and base plate25. Gear 23 b is operably coupled with threaded shaft 24 b and baseplate 25. The rotation of gear 23 a can be initiated manually, or byengaging teeth 30 with a tool. Alternatively, rotation may be initiatedwith robotic assistance. Gear 23 a rotates in a first directionindicated by Arrow B. This rotation in a first direction initiatesrotation of gear 23 b in a second direction indicated by Arrow C. Thissecond direction is opposite that of the first direction. For example,if gear 23 a is rotating in a clockwise direction, gear 23 b rotates ina counterclockwise direction (FIG. 3Ai). The rotation of gears 23 a and23 b initiates rotation of threaded shafts 24 a and 24 b, the rotationextending the shafts 24 a and 24 b in a direction axial (indicated byarrow D) to the longitudinal axis 31 of the implant 22. The shafts 24 aand 24 b can be extended until they separate the adjacent bony surfacesby contacting and engaging one of the adjacent bony surfaces.

The threading and gears of implant 22 can be arranged in various ways toprovide a wide range of treatment options. The threading of each shaftmay be of the same or different pitches. The shafts can exhibit the sameor opposite threading. For example, in the implant 22 shown in FIG. 3A,the threaded shafts 24 a and 24 b exhibit opposite threading, i.e. shaft24 a has a left-handed thread 33 and shaft 24 b has a right-handedthread 34. If the shafts have equivalent threading 35, gears 23 a and 23b can be uncoupled and a third gear 36 placed there between (FIGS. 3Eand 3F). Gear 36 rotates in an opposite direction (indicated by Arrow E)from the direction (indicated by Arrows F) of gears 23 a and 23 b (FIG.3F).

Alternatively, the gears 23 a and 23 b can be uncoupled, and threadedshafts 24 a and 24 b can operate independently of each other. Anembodiment of the implant 22 ii has uncoupled gears 23 a and 23 b (FIG.3D). This arrangement enables each shaft to extend to a differentheight, if necessary, for example, to remove pressure from one area orto provide pressure to an injured area such a bone fracture.

Either or both threaded shafts 24 a and 24 b can be hollow formingspaces which can function as receptacles 37 a and 37 b for insertedmaterial 38. For example, as shown in FIG. 3C, the hollow interior 37 aof shaft 24 a is accessible through a hole or aperture 40 at a top end39. The inserted material 38 can include osteogenic material, bone graftmaterial, growth factors, differentiation factors, hormones, cytokines,and combinations thereof. After installation of the implant 22, insertedmaterial 38 can maintain contact with the bone through aperture 40. Thiscontact facilitates fusion of the bony surfaces. Although the implant 22does not require any supplemental fixation, further fixation of theimplant in the body can be accomplished with the installation of devicessuch as rods, screws, and plates. Openings 41 for installation of suchdevices are shown in FIG. 3E.

In the embodiment illustrated in FIGS. 4-9, the implant 43 includes apair of actuation gears (44 a and 44 b) associated with at least twothreaded shafts (45 a and 45 b) interposed between a top plate 46 and abottom plate 47. Although this embodiment is exemplified by two threadedshafts, three or more shafts may be used. The first collapsedconfiguration of implant 43 is shown in FIG. 5 and the second, expandedconfiguration in FIG. 4. A cross-sectional view of the implant of FIG. 4is shown in FIG. 7 in an expanded configuration.

The top plate 46 has an exterior surface 48 and an interior surface 49,the interior surface 49 including at least a first threaded shaft 45 aand a second threaded shaft 45 b extending from or connected thereto.The first threaded shaft 45 a and the second threaded shaft 45 b aresubstantially parallel. The first 45 a and second 45 b threaded shaftsexhibit opposite threading, 50 and 51. For example, if the firstthreaded shaft 45 a has a left-handed thread 50, the second threadedshaft 45 b has a right-handed thread 51 and vice versa.

The bottom plate 47 also has an exterior surface 52 and an interiorsurface 53, the interior surface 53 including a first housing 54 aconfigured for receiving the first threaded shaft 45 a and a secondhousing 54 b configured for receiving the second threaded shaft 45 b.

Mechanical interaction of the pair of gears 44 a and 44 b with thethreaded shafts 45 a and 45 b extends the top plate 46. The first gear44 a of the pair is operably coupled with the first threaded shaft 45 aand the second gear 44 b of the pair is operably coupled to the secondthreaded shaft 45 b. Upon actuation, the first gear 44 a rotates in afirst direction. This rotation of the first gear 44 a in the firstdirection initiates rotation of the second gear 44 b in a seconddirection opposite the first direction (FIG. 3Ai). This activation ofthe pair of gears 44 a and 44 b rotates the shafts 45 a and 45 b toextend the top plate 46. The extended top plate 46 contacts and engagesone of the adjacent bony surfaces such that the bony structures areseparated by the expanded implant.

Shaft 45 a is displaced by being urged by moving threads associated withgear 44 a, wherein a thread face of gear 44 a pushes against a threadface of shaft 45 a. As shaft 45 a may only move in a longitudinaldirection, the rotational movement of gear 44 a is translated to cause acorresponding longitudinal movement of shaft 45 a.

On one or both of the exterior surfaces of the top and bottom plates 48and 52 can include a plurality of protrusions 55 a and 55 b,respectively. The protrusions enhance engagement of the plates with thebony structures and contact and/or may additionally extend into the boneto stabilize and secure the implant in place. This mechanism limits thepossibility for dislodgement or loosening of the implant over time suchthat the patient is provided with a long-lasting device requiringlimited adjustments and/or replacement.

Referring now to FIG. 6, in an embodiment of the implant, the top plate46, bottom plate 47, or both plates can additionally include at leastone opening or aperture 56 through which material may be inserted into afirst hollow space 57 a or second hollow space 57 b between the interiorsurface of the top plate 49 and the interior surface of the bottom plate53. The size of the first hollow space 57 a increases as the top plate46 is expanded (illustrated in FIG. 4 and FIG. 7). Furthermore, eitheror both threaded shafts 45 a and 45 b can be hollow forming spaces whichcan function as receptacles 64 a and 64 b for inserted material (FIG.7).

The material can be an osteogenic material capable of facilitating bonegrowth thus enhancing and/or accelerating fusion, such as bone graftmaterial, growth factors, and/or differentiation factors. Withenhancement or acceleration of fusion, the patient may have minimal painand decreased length of post-operative recovery, and thus be able toreturn to normal activities faster than with use of the implant alone.The bone graft material may be any art-acceptable grafting material,including, but not limited to, autograft, allograft, xenograft,artificial mixtures, synthetic mixtures, demineralized bone matrix,hydroxyapatite mixtures, and combinations thereof.

For some patients, the presence of bone graft material alone may notachieve the rate of growth sufficient for fusion to occur. In thesecases, an effective amount of a growth factor, differentiation factor,cytokines, and/or hormones can be added to the bone graft material,including, but not limited to bone morphogenic protein (BMP),transforming growth factor .beta.1 (TGF.beta.1), insulin-like growthfactor 1 (IGF-1), platelet-derived growth factor (PDGF), activin,parathyroid hormone, fibroblast growth factor (FGF), LIM mineralizationprotein (LMP), and combinations thereof. The inserted materialadvantageously creates a contiguous contact with the existing bones foroptimal fusion to occur. Thus, while material could be inserted into thecollapsed implant prior to installation, additional material can beinserted after the implant is installed and prior to closing theincision.

The implant allows infinite expansion and retraction, within practicallimits defined by tolerances and precision of manufacturing, over arange specified by about the length of the threaded shafts. Prior toactuation of the gears and threaded shafts, the implant exhibits acompact, retracted, or collapsed configuration. The reduced height has,at least, the advantages of allowing for minimally-invasive insertionrather than an insertion with traditional open surgery, and decreasingimpact on tendons, nerves, blood vessels, and other body tissues, wheninserted. Thus, the patient receives the benefits of minimally-invasivetechniques such as small scars, reduced tissue necrosis, minimized bonedissection, reduced chances of infection, minimized blood loss, reducedtrauma to tissues, minimal postoperative pain, shorter hospital stays,shorter recovery periods, and/or reduced costs.

The implant can be incrementally expanded from the reduced position insitu to restore the height and preserve the structure of the disc space.The expansion property of the implant allows for intraoperativepositioning and adjusting for each individual patient to achieve abetter fit and to decrease postoperative dislodgement. Although theimplant does not require any supplemental fixation, postoperativedislodgement may be further avoided with additional fixation of theimplant in the body by installation of devices such as rods, screws, andplates. Furthermore, the implant is easily manipulated and is capable ofcollapse and repositioning as benefits the patient.

The invention also provides methods for using the implant to facilitatearthrodesis or fusion of adjacent spinal vertebrae. Although this methodis described and illustrated for fusion of vertebrae, it is suitable forfusion of any adjacent bones or joints, such as the ankle or knee. Themethod is not limited to the embodiments described herein.

After anesthetizing the patient, a surgical incision is made to accessthe two adjacent vertebrae to be fused in the patient's body. Thesurgeon may use a posterior approach, anterior approach, lateralapproach, or any other approach deemed appropriate for the patient. Theimplant is collapsed for insertion. Osteogenic material may be insertedinto the hollow spaces at this time, or may be inserted during or afterplacement of the implant through the apertures in the threaded shafts.For example, in the collapsed configuration, prior to insertion,material may be added into space 57 b, and after insertion into spaces57 a, 64 a, and/or 64 b (FIGS. 5 and 7).

The accessed space between the vertebrae is prepared for insertion ofthe implant. In preparing the space the surgeon may do one or more ofthe following: discectomy, dissect and remove bone (laminectomy,laminotomy, and foraminotomy), and reposition or remove cartilage,including removal of all or part of the vertebral endplates and/orcortical bone. The implant is then inserted into the prepared spaceusing any minimally-invasive technique, for example, the collapsedimplant can be inserted into a cannula and monitored via endoscope.

Placement of a collapsed implant 58 into the intervertebral disc space59 between adjacent vertebrae 60 a (top) and 60 b (bottom) isillustrated in FIG. 8. The implant 58 may or may not completely fill theintervertebral disc space 59. The alignment of implant 58, representedby lines 61 a and 61 b, is substantially parallel with longitudinal axis62. After the implant is correctly positioned in the intervertebral discspace, the pair of gears is mechanically activated via manual or roboticengagement of a tool with the teeth of a gear. The rotation of the gearrotates the shaft to extend the top plate in the direction of thevertebral body. The top plate then contacts the vertebral endplates,cortical bone, and/or the cancellous bone to compress and distract thevertebral bodies.

In order to expose the cancellous bone, removal of all or part of thevertebral endplates and cortical bone layer can be done. It isadvantageous for the implant to be in contact with the bone marrow asthe bone marrow provides osteoprogenitor cells which enhance the growthand formation of new bone. When proper distraction is achieved theimplant is adjusted to a therapeutically-acceptable height for thepatient. A “therapeutically-acceptable” height is any height thatprovides beneficial to the patient, i.e. reduced pain, reduced pressureon nerve roots, restoration of joint function, restoration of motion,and/or repair of diseased or injured conditions. The implant may becollapsed and re-extended if necessary for a better fit if the insertionis not secure or the height is incorrect, or a condition in the patientchanges.

Furthermore, after surgery, if the implant needs any adjusting orrepositioning the gears of the implant may be accessed and adjusted viaa minimally-invasive procedure. Thus, the need for replacement implantsis decreased, and in turn, decreasing pain and costs for the patient arerealized. Positioning of the expanded implant 63 into the intervertebraldisc space 59 between adjacent vertebrae 60 a (top) and 60 b (bottom) isillustrated in FIG. 9. Implant 63 is positioned at an angle such thatlines 61 a and 61 b are no longer parallel with longitudinal axis 62. Inthis way, the implant 63 restores and maintains the normal curvature(lordosis) of the spine.

After the desired fit is achieved, an adhesive or glue can be applied toprevent further unnecessary rotation of the gears. Although the implantdoes not require any supplemental fixation with devices such as rods,screws, and plates, these devices can used. When the implant ispositioned and secured in the desirable manner, the surgical incision isclosed and the patient is allowed to heal.

It should be understood that relative terms such as “top” and “bottom”are provided to aid in understanding the invention; devices inaccordance with the invention may be implanted in any orientation themedical practitioner deems best for the patient.

All patents and publications mentioned in this specification areindicative of the levels of those skilled in the art to which theinvention pertains. All patents and publications are herein incorporatedby reference to the same extent as if each individual publication wasspecifically and individually indicated to be incorporated by reference.

It is to be understood that while a certain form of the invention isillustrated, it is not intended to be limited to the specific form orarrangement herein described and shown. It will be apparent to thoseskilled in the art that various changes may be made without departingfrom the scope of the invention and the invention is not to beconsidered limited to what is shown and described in the specification.One skilled in the art will readily appreciate that the presentinvention is well adapted to carry out the objectives and obtain theends and advantages mentioned, as well as those inherent therein.Drawings are not to scale.

The spacers, implants, methods, procedures, and techniques describedherein are presently representative of advantageous embodiments, areintended to be exemplary and are not intended as limitations on thescope. Changes therein and other uses will occur to those skilled in theart which are encompassed within the spirit of the invention and aredefined by the scope of appended claims.

Although the invention has been described in connection with specificembodiments, it should be understood that the invention as claimedshould not be unduly limited to such specific embodiments. Indeedvarious modifications of the described modes for carrying out theinvention which are obvious to those skilled in the art are intended tobe within the scope of the following claims.

1. A method for facilitating fusion of two adjacent joint surfaces in apatient comprising the steps of: accessing a site in the patient's bodyhaving two adjacent joint surfaces to be fused; providing an expandableimplant having a first, collapsed height; preparing a space between thetwo adjacent joint surfaces for insertion of the implant; inserting theimplant into the prepared space; wherein the expandable implantcomprises: a first and second threaded shaft; a base plate coupled tothe first and second threaded shaft; and a first and second gearoperably coupled with the first and second threaded shaft and said baseplate, said first and second gear having interior surfaces includingthreads matably engaged with said first and second threaded shaft,whereby rotation of said first and second gear initiates displacement ofsaid first and second threaded shaft within said base, whereby saidfirst and second threaded shaft are extendable in a direction away fromsaid base plate; wherein the first and second shaft are coupled to a topplate, wherein the first and second gear are coupled to each other,wherein the first and second gear are positioned substantiallyperpendicular to the base plate and adjacent to one another, wherein thefirst and second gear are configured to be operated independently ofeach other. expanding the expandable implant; and closing the site inthe patient's body.
 2. The method of claim 1, further comprising a stepof selecting a material for inserting through an opening in said shaftto fill a hollow interior of said shaft.
 3. The method of claim 2,wherein the selecting step comprises selecting a bone graft materialfrom the group consisting of autografts, allografts, xenografts,artificial mixtures, synthetic mixtures, demineralized bone matrix,hydroxyapatite mixtures, and combinations thereof.
 4. The methodaccording to claim 3, wherein the selecting step further comprisesselecting an effective amount of a growth factor or differentiationfactor.
 5. The method according to claim 4, wherein the selecting stepcomprises selecting a growth factor or differentiation factor from thegroup consisting of bone morphogenic protein (BMP), transforming growthfactor, insulin-like growth factor, platelet-derived growth factor(PDGF), activin, parathyroid hormone, fibroblast growth factor (FGF),LIM mineralization protein (LMP), and combinations thereof.
 6. Themethod of claim 1, further including a step of inserting the materialthrough an opening in said shaft to fill a hollow interior of the shaft.7. A method for facilitating fusion of two adjacent joint surfaces in apatient comprising the steps of: providing an expandable implant forinsertion in a space between adjacent bony structures, comprising: afirst and second threaded shaft; a base plate coupled to the first andsecond threaded shaft; and a first and second gear operably coupled withthe first and second threaded shaft and said base plate, said first andsecond gear having interior surfaces including threads matably engagedwith said first and second threaded shaft, whereby rotation of saidfirst and second gear initiates displacement of said first and secondthreaded shaft within said base, whereby said first and second threadedshaft is extendable in a direction away from said base plate; whereinthe first and second gear are positioned substantially perpendicular tothe base plate and adjacent to one another, wherein the first and secondgear are coupled to each other, wherein the first and second gear areconfigured to be operated independently of each other, expanding theexpandable implant.
 8. The method according to claim 7, wherein theimplant has a first, collapsed height prior to extension of said firstand second threaded shaft and a second, expanded height after extensionof said first and second threaded shaft.
 9. The method according toclaim 8, wherein the second, expanded height is adjustable.
 10. Themethod according to claim 7, wherein the implant is operable to distractthe adjacent bony structures.
 11. The method according to claim 7,wherein the space for insertion is the intervertebral space between twoadjacent spinal vertebrae.
 12. The method according to claim 7, whereinsaid first and second threaded shaft have a hollow interior.
 13. Themethod according to claim 7, wherein a top end of said first and secondthreaded shaft includes an opening, the opening operable for insertionof material into said hollow interior.
 14. The method according to claim13, wherein the material is a bone graft material selected from thegroup consisting of autograft, allograft, xenograft, artificialmixtures, synthetic mixtures, demineralized bone matrix, hydroxyapatitemixtures, and combinations thereof.